School Attendance, Chronic Health Conditions and ... ... absenteeism is a compelling indicator for education

School Attendance, Chronic Health Conditions and Leveraging Data for Improvement: Recommendations for State Education and Health Departments to Address Student Absenteeism

PUBLISHED 2016

Acknowledgements

NACDD would like to thank the following people for valuable contributions into the development

The document’s contents are solely the responsibility of the author and do not necessarily

Amanda K. Martinez (author) – National Association of Chronic Disease Directors

Hedy Chang – Attendance Works

Deborah Chameides – Hartford Public Schools, Connecticut

Cheryl De Pinto – Maryland Department of Health and Mental Hygiene

Laura DeStigter – American Academy of Pediatrics

Nancy Dube – Maine Department of Education

Karen Erwin, Angela McDonald, and Cheri Meadows – Kentucky Department of Education

Mary Ann Gapinski – Massachusetts Department of Public Health

Christy Haas-Howard – Denver Public Schools, Colorado and Colorado Department of Education

Donna Heins and Kari Sullivan – Connecticut State Department of Education

Mike Herrmann and Lori Paisley – Tennessee Department of Education

Jessica Hollenbach and Christine Langton – Connecticut Children’s Medical Center

Rachelle Johnsson Chiang – National Association of Chronic Disease Directors

Alexandra Mays – Healthy Schools Campaign

Karie Mulkowsky – Food Allergy Research & Education

Ann Nichols – North Carolina Division of Public Health

Sonda Oppewal and Debbie Travers – University of North Carolina at Chapel Hill

Isabelle Barbour – Oregon Health Authority

Margret Schnitzer – Baltimore City Health Department, Maryland

Catherine Sparks – Former Utah Department of Health

Francine Truglio – New Britain Health Department, Connecticut

Joseph Vaverchak – Consolidated School District of New Britain, Connecticut

Amy Wiseman – E3 Alliance, Texas

Steering committee members of Step Up & Be Counted! National School Nurse Standardized Data Set, a joint initiative by the National Association of School Nurses and the National Association of State School Nurse Consultants:

Martha Dewey Bergren – University of Illinois - Chicago

Marjorie Cole – Missouri Department of Health and Senior Services

Kathleen Johnson – Seattle Public Schools, Washington

Erin Maughan – National Association of School Nurses

Estelle Watts – Mississippi Department of Education

Linda Wolfe – Delaware Department of Education

If you require this document in an alternative format, such as large print or a colored background, please contact amartinez@chronicdisease.org or 770-458-7400.

This publication was supported by the Cooperative Agreement Number 5U380T000225-3 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the author and do not

mailto:amartinez@chronicdisease.org

School Attendance, Chronic Health Conditions and Leveraging Data for Improvement | NACDD | 1

Introduction and Purpose

The impact of school attendance and absenteeism on student academic success and educational attainment is well documented, as is the effect of education on health and other outcomes. Absences are associated with lower test scores including reading skills and higher dropout rates that can negatively affect high school graduation and college readiness.1, 2, 3, 4 Higher education levels tie to better health outcomes including less chronic illness and improved social and economic outcomes.5, 6 Reducing absenteeism is a compelling indicator for education and an important ingredient for improving population health and health equity and positioning students for lifelong success.a

The many causes of school absence can be interdependent and complex. Chronic health conditions are described as physical, developmental, behavioral or emotional conditions that last for a prolonged time period, require more than routine health services, and can affect usual childhood activities,7, 8, 9 and they may contribute to absence.10 Asthma, for instance, is one of the most common chronic health conditions among children and a leading cause of school absenteeism.11 Children living in poverty are disproportionately affected by absenteeism and chronic health conditions.1, 10

Millions of students diagnosed with or at risk for chronic health conditions attend school. An estimated 15.9% and 17.5% of children ages 6-11 and 12-17 years old, respectively, have at least one of 18 chronic health conditions measured in the National Survey of Children’s Health (e.g., asthma, diabetes, epilepsy or seizure disorder, etc.).12 Childhood chronic health conditions lower educational attainment, and school absences increase this association.13 Students with chronic health conditions are at risk of missing school because of their disease or its progression. If their conditions are not

a Health equity is ‘attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities,’ according to Healthy People 2020. http://www.healthypeople.gov/2020/about/foundation- health-measures/Disparities

managed appropriately, adverse symptoms or a need for medical treatment during the school day may keep them from attending school. Those having physical conditions may also experience increased stress and co- occurring psychological illness that can negatively affect coping, treatment adherence, and consequently school attendance.9, 14 Students with chronic health conditions can have accommodations addressing attendance through written plans such as Individualized Education Programs (IEP), Section 504 plans, and Individualized Healthcare Plans (IHP), but it is still important for schools to do what they can to support and keep them in school to a most optimal level possible.b

Confronting absenteeism calls for cross-sector engagement to gather data examining absence and possible related causes, and to prioritize and implement coordinated interventions that keep students attending school. In partnership with schools, state education and health departments can play a pivotal leadership role to shape policies and practices in reducing absenteeism through a comprehensive approach that is inclusive of addressing chronic health conditions. This document is for state education and health departments through the lens of school health services and focuses on the ways state school nurse consultants and additional state school health personnel can provide support to schools. It emphasizes school nursing and the role of school nurses in data collection and use. Nursing leadership is integral to managing the care of students with chronic health conditions. School nurses are associated with improved attendance and their interventions, including case management, contribute to positive educational and health effects.15, 16, 17 In addition, school nurses coordinate care to improve linkages between the medical home, family and school and collaborate with others to reduce health-related barriers to learning and better position students for success.c, 18

b Protecting Students with Disabilities: Frequently Asked Questions about Section 504 and the Education of Children with Disabilities,

c The medical home concept is “…a cultivated partnership between the patient, family, and primary provider in cooperation with specialists and support from the community.” One of the criteria is to determine if a child has a physician (e.g., primary care provider) or nurse who knows the child well and is a usual source for health care. http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/ BuildingMedicalHome/whyimportant.html

http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities http://www2.ed.gov/about/offices/list/ocr/504faq.html http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/BuildingMedicalHome/whyimportant.html http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/BuildingMedicalHome/whyimportant.html

2 | NACDD | School Attendance, Chronic Health Conditions and Leveraging Data for Improvement

The purpose of this document is to 1) raise awareness on the connections between school attendance and chronic health conditions, 2) promote the notion that more can and must be done to integrate

aimed at improving school attendance, and 3) give recommendations for actions to take in this area. An additional aim is to exemplify strategies and best practices for addressing absenteeism that already exist and identify how states and schools advance their implementation. Importantly, approaching health in schools within a framework that aligns with educational goals (e.g., improving academic achievement, reducing achievement gap, etc.) is critical. Actions to collect and use attendance data in relation to students with chronic health conditions should be in concert with goals that matter most to schools.

The recommendations are based on a review of relevant national and state resources and key informant interviews with stakeholders at the national, state, and local levels. The document additionally features:

k Discussi